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` STATE OF CALIFORN! WATER RESOURCES CONTR` BOARD,. ••°..�... FORM 'S" UNDERGROUND STORAGE TANK P GRAM !k TANK PERMIT APPLICATION INF MOTION. TANK. �,. .,COMPLETE A SEPARATE FORM WITH THE FQLLOWIN I RMATION FOR EACH TANK. _- , 1O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5'CHANGE OF INFORMATION ❑7 P ANENTLY CLOS ONE ITEM ' '- ?❑2 II�ITERIM.PEfiMIT ❑"4 AMENDED PERMIT Elfi:TEMPORARY TANK CLOSURE p TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: :71d h LD J: '11. F FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION--tCOMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY , W A. OVVNERSTANKID#', ` B. MANUFACTUREDBY: C.'YEAR INSTALLED :', D. TANK CAPACITY IN GALLONS: SQ .IL TANK CONTENTS'° '!-'IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM LD. Y A. ❑ 1 MOTOR VEHICLE FUEL ❑2 ELM'. B• C. ❑ 1 UNLEADED ❑�2 LEAPED ❑ 3 DIESEL ❑3CHEMICAL PROpUCT ❑ OIL .. ❑ 1 DUCT ❑4 GASAHOL E:]I5 JET FUEL ❑ 6 AVIATION GAS 11 ` ❑5'HAZARDOUS'.` —] 80 EMPTY 5.6NKNOWN 2 WASTE :❑7 METHANOL ❑r �'I99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF i /r HAZARDOUS_SUBSTANCE STORED&C.A.S.# C,•A•S.#: III. TANK C ONSTRUCT19N MARK ONE ITEM ONLY IN BOX A,B,C,3 D iF Y A TYPE OF ❑ 1 LE W F-1'3 SINGLE WALLED NTH EXTERIOR LINER �'❑ 95 UNKNOWN SYSTEM - 2 SIN�ALLED ❑4 SECANDARYCONTAINMENT .❑99 OTHER EP:1'STEEL/1RON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS !:❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK E],5 CONCRETE ❑6 POLYVINYLCHLORIDE -❑ 7 ALUMINUM E ❑8IW%METHANOL COM PATIBLEFRP MATERIAL:. ❑9 BRONZE ' ❑10 GALVANIZED STEEL ❑.95 UNKNOWN :❑99 OTHER r ❑ ti RUBBER ONED ❑2 A LINING ❑3 EPDXY UNING Ij❑4 PHENOLIC UNING . . C.INTERIOR_ f LINING ❑'6 GLASS UNING - UNLINED' 95 UNKNOWN ❑ ES LINING MATERIAL COMPATIBLE WITH 10096 M L? ❑YES ❑NO ��❑ 99 OTHER D.CORROSION ❑ 1;POLY&HLENE WRAP. ❑ 2 OR ASPHALT E]3 VINYL WRAP, E t[D4 FIBERGLASS REINFORCED PLASTID ' PROTECTION .ED CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN s❑99 OTHER f IV. ,PIPING INFORMATION CIRCLE A IF ABOVE GROUND,-U IF UNDER i, OTH IF APPLICABLE A SYSTEM TYPE A U 1.SUCT A U. 2 PRESSURE 3 GRAVITYj A U-91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A INGLE WAL A .U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U.1 STEE A U 2 STAINLESS STEEL A U' 3 POLYVINYL CHLORIDE(PVC) A U 4{FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U. 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WYFRP A U 6 h100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL,CHECK :. P 8.•2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 NIC MONITOR P S{ 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 8 95 U KNOWN P 8 99 OTHER ,F VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE �- 1. ESTIMATED,DATE LAST USED,(MO/YR) 7F 2. ESTIMATED QUANTITY OF � ' 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONSli THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO;THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED d SIGNATURE) f DATE li. LOCAL AGENCY USE ONLY : COUNTY Y JURISDICTION# _ - AGENCY# E FACILITY ID# }. TANK ID#. 3q o1 ay � � aovy r CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME - PHONE•WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMIT AMOUNT ''flCHARGE AMT. FEE CODE BY: I ter• - - t � FORM B(6-29-88) THIS FORA MUST BE ACCOMPANIE A fACILITYISITE APPLICATION, FORM IN,UNLESS AbdI�RENT`FORM'N HAS BEEN FILE A F'.ITOGFS1_l3G.CG1T?v .z